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I OR OFFICE USE: II ii - -- -------- -- ------------------------ -------I�_ APPLICATION FOR SANITATION PERMIT Permit No. - - - -------- - i (Complete in Duplicate) I _____________ __ ----------------�.__{__.._ �_ This Permit Expires 1 Year From Date Issued Date Issued ,ZZApplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. s application is made in compliance with County Ordinance No. 549. t.67,6 IC! I JOB ADDRESS AND LOCATION_!Y._•_L-_ --•��•�t--------------- 'E` � Y- ------ eT--------------------- Owner's Name------- --- 'I ------------•------------••------- -------- ------------------------------------------- Phone------------------------------------ I! li Address__. ••... -•------- -- --i-- ------ Contractor's Name---------- - -- ---- -------- ------------ --------------------------------- Phone----------------------------------- Insta"llation will serve: Residence +[�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [] I� Number of living unit.. .---/- Number of bedrooms ___Number of baths __/--- Lot size ----. _ __ ______________________________ Water Supply: Public system. ❑ Community system ❑ Private [5--'Depth to Water Table -------- ft, Chaeacter of soil to a depth Of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date....................1 No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPlE,OF„INSTALLATION,AND SPECIFICATIONS: (No septic tank or cesspool pe Imre'fled if public sewer is available within-200 feet:)-'- ��— ,, ,�, Sepfic Tank: Distance from nearest well_________________Distance from foundation--------------------Materiaf----------------------.___________.__._._______- No. of compartments--------------------------Size--------------------------------Liquid depth_-------------------------Capacity------------------ ---- Dispos field: Distance from nearest welL.___aS_p_'_Distance from foundation-----l�_.........Distance to nearest lot line--.f- [• Number of lines--------)------.------------------Length of each line----- _c--_!_______________Width of trench__' ----------------------------- Type _`_--._____-.________-_.Type of filer material--___4a�'.a2_r_-__-_.Depth of filter material------�_.�--' --_-.Total lengfh_____ Seepage Pit: Distance t1ib nearest well--- ------------_-----Distance from foundation--------------------Distance to nearest I] Number of pits----------------------Lining material-----------------------Size: Diameter---------------._-.----Depth------------------------------•-- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_- ---------------------------------- [� Size: Diameter---- - ------------------------------Depth--------------------------------- -----------------Liquid Capacity----------------------------gals, y I Priv .: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ Distance to nearest lot line--------------------------------- - - ----- - ----- ------------a ----- - Y Remodeling and/or repairing __________________________ _ ` ii l ,, - .A = 'M----------- ,l I�. -------------------------------------------------•--------------------------------------------------------------- ----- ------- I] hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. [Signed} = �' - ----------------------- and/or Contractor) ---- O-K .rte a I y:-----------------------------------..._..---------- ---- -------------- -------ATitle) ------------------------------------- -------------- --- ----.-...------------ - - (Plot,plan, showing size of lot,--location of system in relation to wells, buildings, etc., can be placed on reverse side). J� :11. FOR DEPARTMENT USE ONLY a i APPLICATION ACCEPTED BY__ .. -- ...... ----- -------------------------------------------------- DATE-----j REVIEWEDBY----- -------------------� ---------- --------------- --------------- -------------- -------------------------------- DATE------------------------------------ BUILbINGPERMIT ISSUED---AI------------------------------------------------------------------------------ ----------------- DATE------------------------------ ----------------------------- Alter�ations and/or recommendations-------- ------ ----------------------------------------•-••-----------------------------------•---------------------------- ii _ !I !I 1 1 .!I ---------------------------------- ------•----------------- --------------------------------------- ----------------------------- ----------------------------------------------------- ---------------- ----- ------ -------------------- ------ ------------------ -------------- -- -------- ----------------------------------------------------------------------------------------------------------------- -------------- 11 ------ ------------------ I1 IN' _ FINAL INSPECTION BY: ZP ------------ ---------- Date ---------------------------------G� ----------- ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT ij 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street i± Stockton,California Lodi,California Manteca,California Tracy,California